An interdisciplinary team caring for children with type 1, or juvenile, diabetes launched a creative arts experience in a hospital-based summer program. The program included group activities such as dramatic skit development as a health promotion and harm-reduction intervention. The fundamental goal of the summer program was to offer education and counseling to children with diabetes and their caregivers to increase their knowledge and competence in daily monitoring and care.
For the children, the program’s particular purpose was to increase their knowledge about their illness and provide opportunities to share psychosocial concerns that could block learning or application of knowledge in their daily lives. Specifically, the children’s program goals included helping them accept and better understand their condition and assume age-appropriate responsibility for self-care and shared monitoring with caregivers.
Practice Context and Program Description
Following a referral from a family physician, a nurse educator from the hospital-based continuing care program begins a teaching component, usually in the hospital, and maintains outpatient contact with the physician, children, and caregivers as often as necessary. The nurse educator is the primary care contact for children and caregivers as the families learn to cope with the demands of a chronic illness. Scheduled quarterly teaching modules provide “boosters” of medical management and nutrition data to the families.
The summer program is an integral part of the hospital-based program that is offered throughout the year; it is the one quarterly meeting opportunity in which all available families in the region are invited to come together. Newly diagnosed children and their caregivers, as well as those diagnosed earlier, are invited to attend the summer session. Those diagnosed earlier usually attend for the first 2 or 3 years following the initial diagnosis. Attendance varies each year; repeat attendance usually lessens as the children mature and more readily incorporate daily self-care responsibilities.
Program Staffing and Directions
At the time the arts intervention was developed, two nurse educators, a nutritionist, and two social workers constituted the interdisciplinary team. During the summer program, the nurse educators provide medical information; the nutritionist educates about healthy food choices; and the social workers provide opportunities for discussions about caring for diabetes within the participants’ social lives.
The children and their care-givers are separated and have different group experiences. In the caregivers’ group, participants receive information on nutrition, medical management, advances in treatment, and coping with stresses associated with caring for their children. In the children’s group, participants learn about healthy functioning, self-care issues, and how to assume age-appropriate responsibility for necessary medical controls. This article focuses on the unique aspects of the children’s groups.
Design and Structure of Children’s Groups
In the summer program, groups are organized by the children’s ages, and content is tailored to correspond to their developmental abilities. At the time this article was written, the program for younger children ages 4 to 7 and their caregivers took place for 1 week in early July; the following week’s program was for older children ages 8 to 12 and their caregivers. The children’s groups ranged in sizes up to 18 children and included a mixture of boys and girls.
The caregivers’ and children’s groups were offered Monday through Thursday from 8:30 a.m. to 1:30 p.m. and included snack breaks and a combined group lunch. The first 90 minutes usually involved a blend of medical, exercise, and nutritional information sessions, with a nutrition break from 10:00 to 10:20 a.m. During this particular summer program, on Monday, Tuesday, and Thursday, a group-oriented creative arts experience was offered from approximately 10:30 to 11:45 a.m.
The Creative Arts Intervention
A nurse educator and a social worker joined together to co-facilitate the children’s group activity and equally shared the roles of both drama coach and children’s group leader. The leaders introduced the concept of creative arts and elements that support it (e.g., character and plot development, camera work, props). They identified the children’s feelings about the group activities, having a camera in the room, the leaders, and each other; addressed unfolding group dynamics and problem solving skills; and practiced social reinforcement.
The creative arts experience began by the leaders inviting the children to come together in a circle. In the first session, special attention was given to the warm-up exercises, which helped the children feel more comfortable expressing themselves. The exercises were designed to help the children prepare for further creative expressions in the group.
One of the warm-up exercises included asking the children to guess a covered mystery object one of the leaders was holding. Another exercise asked the children to enact a well-known movie or television persona while the others guessed who it was. In another exercise, the children were asked to pretend to reach for an imaginary, unknown object from an invisible mystery box and then pretend to pass or throw the object to each other, finding out what it was after the entire group had handled it.
Group discussion immediately followed the warm-up exercises, and the children were asked to describe their reactions and responses to the activities in this phase. Many children reported that they liked the freedom and license the role-playing gave them. The pattern of engaging in an activity then discussing it set the stage for continued explorations of meanings associated with the activities.
The leaders explained to the children that they had an opportunity to develop a skit together over the 3 days, videorecord it daily, view it together, then discuss the processes they shared together. The videocamera was explained as a tool for all to use and a means to enjoy skit production. All group members agreed on maintaining confidentiality about what was said and done in the group. Most children wanted to know whether the caregivers would see the videotape, and they were assured that this was the children’s decision.
The children were encouraged to brainstorm themes, topics, and ideas related to their illness that the group might develop into skits. While nurturing the children’s explorations of the characters and stories they might enact, the leaders encouraged a sense of belonging among members. They also fostered team-work, group trust, and caring as group norms. Consistent with therapeutic factors outlined by Yalom (1995), the leaders’ purposes were to increase awareness of universality among the members (i.e., self and others being in a similar situation) and facilitate cohesion, interpersonal relationships, and altruism among the members, leading to heightened feelings of hope.
Bringing the Children on Board
Creative arts activities in children’s groups rely on the natural lure and attraction of pretend play, which enables children to examine issues of emotional well-being and experience helpful social interactions (Gariepy & Howe, 2003; Hoey, 2005). Within the creative arts activities, the children were encouraged to identify concerns, enact problems, and discuss their responses and any barriers to healthy functioning. The process of group development was captured in the following steps in which children:
- Shared their perceptions of diabetes and themselves.
- Examined issues that were potential focal points for development in the skits.
- Explored views of the people and problems to enact in the skits.
- Tried out new personas and different ways to express themselves.
These activities were followed by group discussions, including responses to the skit content and any feedback to be shared with others.
The purposes of these group activities were to reinforce behaviors and attitudes that contribute to health promotion and harm reduction and to provide peer support by connecting individuals, which can be an effective way to help them with anxieties and communication problems (McNamara, 2006; Moore & Russ, 2006). Such groups can help children develop “strategies for handling stress, as well as facilitating positive emotional adjustment [resulting] in both improved metabolic control and better overall functioning in all spheres of life” (Citrin, LaGreca, & Skyler, 1985, p. 181).
The steps of the planning process were discussed with the children: first, the need for a topic; second, roles for actors to play; third, a direction for the action of the play; and last, an ending they would like to see. By using minimal scripting, the children were left to improvise and insert their own personal issues into the skits. The skits presented opportunities for the children to elaborate on their own perceptions of the management of chronic illness, problems associated with parents and siblings, and concerns about their bodies, general state of health, and self-perceptions.
Because children’s first attempt at play acting can be difficult, brief group discussions about the awkwardness of the activity quickly fostered member engagement. When groups got stuck, the leaders suggested the children work on a skit based on a well-known fairy tale, such as Goldilocks, Red Riding Hood, or The Three Little Pigs, because these contained elements of human conditions and dilemmas with which the children might identify (Booth, 2005; Crimmens, 2006).
Each hour spent in creative arts was divided into timed stages. The first 10 minutes were spent in various warm-up exercises and discussion. The children spent the next 10 minutes planning for the skit. They then had 30 minutes to rehearse, work on the skit production, and record it. The last 10 minutes were spent watching the videotaped productions, discussing relationship problems that surfaced in the skit, expanding on their personal concerns and responses to injuries portrayed in the skits, and discussing their fears about health and illness issues.
The following examples of these children’s skits are meant to highlight the basics of the approach and how it increased the children’s knowledge about their illness and gave voice to their psychosocial concerns. The following two examples were drawn from different populations of children with diabetes.
Skit 1. A group of children ages 4 to 7 came together, shared ideas for a skit, and agreed to create one about kids getting sick and needing injections of “Krypton” (sic) to continue living. They portrayed the physicians and caregivers as mechanical robots who lost no time in “needling” the children to make them feel better. They portrayed the children as stunned and numbed individuals. Themes of anger toward professionals and caregivers surfaced regularly as the children identified some feelings of discomfort and confusion in their lives and a rejection of the initial care and help offered by others.
After the skit’s completion, the group watched the videotape and engaged in an energetic and engrossing discussion about how children get diabetes and how it can be managed. The value of multidisciplinary team leadership is apparent when the children’s attention is directed toward a topic of their own choosing with associated impressions and feelings. The skit focuses their attention and permits follow-up discussions through symbolic and direct communications about their illness and personal situations.
Children in this age group often presented their struggles with caregivers by enacting plays that focused on powerful figures in their lives (i.e., physicians, nurses, caregivers). They often struggled with a theme of diminished health and questioned why they could not restore themselves to health without help from others as they dealt with vulnerability to illness or medical complications.
Skit 2. A group of children ages 8 to 12 decided to work on a skit about eating out with friends. Eating out emerged as an important social activity that sometimes sparked tensions between the children and caregivers. The skit they designed took place in a fast-food restaurant with the children outrageously ordering high-calorie and high-fat foods. They handled the authority issues surrounding the food choices as they remembered from their own experiences, then mocked the caregiver’s advice about food choices. They celebrated the denial of diabetes, scoffing and deriding the food limits and exchanges they had learned earlier in the program and filled their imaginary trays with fries, burgers, milkshakes, and sundaes.
As the group watched their production, they became silent. One girl commented aloud that they looked “stupid” in the skit because they were not taking care of themselves. Discussion ensued about the food exchanges they could use to allow for some of the items on the fast-food menu. Another child observed that each participant really was in charge of making healthy choices and not getting into situations where blood sugars are either too low or too high. The leaders reinforced a sense of autonomy and personal responsibility when making decisions, especially in an area such as food exchanges, so children are able to taste and enjoy some of the available treats.
Children in this age group expressed concerns about their caregivers’ lack of trust and at the same time expressed a need to be free to “let off steam” once in a while when it came to controlling their chronic illness. Their skits often focused on eating and blood sugar testing and whether to tell caregivers about any extra food intake and after school snacks. The discussions following the skits were usually lively, as the children struggled with the concepts of earning trust and enacting responsible behaviors.